Received on 07/03/2011. Approved on 03/05/2012. The authors declare no confl ict of interest. Financial Support: Universidade Federal de Minas Gerais. Ethics Committee: 0062.0.203.000-10.
School of Physical Education, Physical Therapy and Occupational Therapy, Universidade Federal de Minas Gerais – UFMG.
1. Master degree in Rehabilitation Sciences; Rheumatologist of the Hospital das Clínicas, UFMG; Preceptor of the Internal Medicine Residency, Hospital Júlia Kubitschek; Professor of the Medical School, Universidade José do Rosário Vellano
2. Physical therapist; Associate Professor, School of Physical Education, Physical Therapy and Occupational Therapy, UFMG 3. Physical therapist; Master degree in Rehabilitation Sciences
4. Radiologist, Axial Centro de Imagens
5. Undergraduate student of Physical Therapy, UFMG
Correspondence to:Rita de Cássia Corrêa Miguel. Escola de Educação Física. Av. Antônio Carlos, 6627 – 3º andar – Unidade Administrativa II – Pampulha. CEP: 31270-901. Belo Horizonte, MG, Brasil. E-mail: ritacmiguel@yahoo.com.br
Frailty syndrome in the
community-dwelling elderly with osteoarthritis
Rita de Cássia Corrêa Miguel1, Rosângela Corrêa Dias2, João Marcos Domingues Dias2, Silvia Lanziotti Azevedo da Silva3, Paulo Roberto Menicucci Filho4, Tatiana Moreira S. Ribeiro5ABSTRACT
Objective: To characterize and compare community-dwelling elderly with knee and/or hip osteoarthritis (OA), focus-ing on the frailty syndrome. Method: Cross-sectional study of the elderly with knee and/or hip OA, using a subsample from the study of frailty in the Brazilian elderly (FIBRA), assessing the following: sociodemographic characteristics, comorbidity, medications, depression, anthropomorphic data, falls, pain, stiffness, physical function, and frailty. The subjective assessment of health was also performed. Results: The fi nal sample comprised 58 elderly (mean age, 74 ± 5.5 years) as follows: 17 (29.31%) non-frail, 28 (48.28%) pre-frail, and 13 (22.41%) frail. The frail elderly received more medications than the non-frail ones (7.00 ± 2.00 and 4.00 ± 2.00, respectively; P = 0.001). The mean Body Mass Index was lower in the non-frail elderly as compared with those of the pre-frail and frail ones (27.00 ± 4.50 kg/m2, 30.00 ± 4.00 kg/m2, and 34.00 ± 8.00 kg/m2, respectively; P = 0.018). Depression was more prevalent in the frail group. Compared to the previous year, there was a difference in the health status of the groups as follows: 64.3% of the pre-frail elderly and 46.2% of the frail ones believed their health deteriorated, and 52.9% of the non-frail elderly considered that their health status remained unchanged (P = 0.016). When comparing the current physical activity levels with those of the previous year, the pre-frail and frail elderly reported a worsening (P = 0.010). Regarding physical function and fall-related self-effi cacy, the frail elderly were worse than the others (P = 0.023 and 0.017, respectively). There were no signifi cant differences between the groups for the remaining items analyzed. Conclusion:
The elderly with OA and frailty use more medications, are more obese and depressed, have a poorer perception of their own health and of their level of activity as compared with that of the previous year, have a worse fall-related self-effi cacy, and worse physical function.
Keywords: frail elderly, knee osteoarthritis, hip osteoarthritis, disable people.
© 2012 Elsevier Editora Ltda. All rights reserved.
INTRODUCTION
The increase in the population’s life expectancy has a
signi-fi cant impact on health conditions, morbidity and functional limitations among the elderly.1 Osteoarthritis (OA) is strongly associated with age and is the most common rheumatic disease,
Frailty is a distinct clinical syndrome in which there is a reduction in the body’s physiological reserves and homeostatic capacity to resist to stressors, due to the cumulative decline of the physiological systems, comprising mainly sarcopenia, neuroendocrine dysregulation, and immune dysfunction.6–9 Fried et al.6 have proposed the operational defi nition of a frailty phenotype, which was used in the present study. Frail elderly are more susceptible to adverse outcomes, such as functional limitation, falls, institutionalization, hospitalization, and in-creased mortality.6
OA is considerably prevalent in studies about frailty, with which it has a signifi cant association.10,11 Nevertheless, in addition to the isolated impact of frailty and OA on the functional capacity and quality of life of the elderly,4,6 no study characterizing the elderly with OA based on the frailty phenotype has been found in the databases assessed. Thus, this study aimed at characterizing community-dwelling el-derly with knee and/or hip OA regarding sociodemographic, clinical, and functional aspects, with emphasis on the frailty syndrome.
MATERIALS AND METHODS
This cross-sectional observational study was approved by the Committee on Ethics and Research (0062.0.203.000-10). All participants provided written informed consent.
From the database of the study Perfi s de Fragilidade em Idosos Brasileiros Residentes na Comunidade (Rede FIBRA, central area of the city of Belo Horizonte) with 607 community-dwelling elderly, all individuals who answered affi rmatively to the question “Have you been diagnosed with arthritis or rheumatism by a physician?” (162 elderly) were selected for contact. The inclusion criteria were age over 65 years and meeting the American College of Rheumatology criteria for knee and/or hip OA.2,3,12 The exclusion criteria were: cognitive defi cit identifi ed in the Mini-mental State Examination,13 previous arthroplasty, diagnosis of systemic rheumatic diseases, impossibility to walk independently, and lack of handgrip strength.
The elderly diagnosed with, or suspected of having, knee and/or hip OA were invited to participate in the study and visited in their homes. During the visits, the clinical diagnosis of knee and/or hip OA was assessed and those who did not meet the criteria proposed in the study were excluded. Once the diagnosis of OA was confirmed, the WOMAC (Western Ontario and McMaster Universities) questionnaire,14 specific to assess pain, stiffness, and physical function domains in patients with knee and/or hip
OA, was applied. Then, the Rede FIBRA questionnaire, containing items that assess sociodemographic charac-teristics, comorbidities, perceived physical health, Body Mass Index (BMI), falls (self-reported and Falls Efficacy Scale – FES-I-Brasil,15 the later according to cut-off points defined by Camargos et al.15 and total score), and depression (self-reported and Geriatric Depression Scale – GDS),16 was used. In addition, that questionnaire contains questions and measures that allow the characterization of the elderly ac-cording to the frailty phenotype proposed by Fried et al.,6 as follows: unintentional weight loss (≥ 4.5 kg), self-reported exhaustion (assessed by use of the questions: “Have you felt you had to make an effort to deal with your usual chores?” and “Have you dropped many of your activities and interests?”, the answers “frequently” or “always” to any of those questions scored one point), weak grip strength (assessed by use of the JAMAR dynamometer, and with the adoption of the cut-off points proposed by Fried6 and adjusted for gender and BMI), low physical activity (as-sessed by use of the Minnesota Leisure Time Activities Questionnaire, according to which, women with a week energy expenditure < 270 kcal and men with a week energy expenditure < 383 kcal were considered fragile for that item), and slow walking speed (time spent, in seconds, to cover a 4.6-m distance at a usual auto-selected speed; the cut-off points proposed by Fried6 and adjusted for gender and height were adopted). According to the number of those characteristics, the elderly were classified as frail, with at least three of those characteristics; pre-frail, with one or two; and non-frail, with none.
The elderly included in the study were invited to undergo radiography of the joints affected at a specialized clinic. The analyses were performed by the same examiner, who was unaware of the elderly’s clinical data. Radiographic OA was classifi ed according to the Kellgren-Lawrence grading system.17
Statistical analysis
The descriptive analysis of the data collected was performed. The chi-square test was used to assess the differences between the frailty levels for the categorical variables.
performed with the SPSS software, version 16.0, with 95% confi dence (α = 5%).
RESULTS
Of the 162 elderly selected, 12 (7.4%) could not be contact-ed. Of the remaining 150, 37 (24.6%) had other rheumatic diseases, 14 (9.3%) denied the presence of rheumatism, and 99 (66.6%) had symptoms of knee and/or hip OA. Of those 99, nine (9.09%) refused to participate, and the others were assessed. Nineteen elderly (19.2%) were excluded, 13 of whom (13.2%) due to arthroplasty, two (2.0%) due to dementia, three (3.0%) who could not walk independently, and one (1%) who could not undergo the handgrip test.
Thus, 71 elderly, who met the clinical criteria for knee and/or hip OA, were included and assessed. Later, 13 of them (18.3%) were excluded from the sample as follows: 10 (14.08%) who refused to undergo radiography and three (4.2%) who had no radiographic changes. Thus, the final analysis comprised 58 elderly: four (6.9%) men and 54 (93.1%) women.
Of the 58 elderly resulting from the fi nal analysis, 17 (29.31%) were classifi ed as non-frail (NF), 28 (48.28%) as pre-frail (PF), and 13 (22.4%) as frail (F). Table 1 shows the sociodemographic characteristics of that population. The mean age of the sample showed no signifi cant difference in the three classes as follows: NF, 74 ± 5 years; PF, 73 ± 6 years; and F, 75 ± 6 years (P = 0.606).
Table 1
Descriptive analysis of the total sample (n = 58) and of the frailty groups, and difference between frailty groups
Variable Total sample NF PF F P Test
n % n % n % n %
Gender Male Female 4 54 6.9 93.1 2 15 11.8 88.2 2 26 7.1 22.9 0 13 0.0 100.0 0.451 Chi-square Marital status Married Single Divorced/separated Widow(er) 22 11 3 22 37.9 19.0 5.2 37.9 5 5 1 6 29.5 29.5 5.9 35.3 11 3 2 12 39.3 10.7 7.1 42.9 6 3 0 4 46.2 23.1 0.0 30.8 0.683 Chi-square Color/ethnicity White Black Mixed heritage or mulatto 34 6 18 58.6 10.4 31.0 9 2 6 52.9 11.8 35.3 17 4 7 60.7 14.3 25.0 8 0 5 61.5 0.0 38.5 0.628 Chi-square Retired Yes No 42 16 72.4 27.6 12 5 70.6 29.4 20 8 71.4 28.6 10 3 76.9 23.1 0.917 Chi-square Schooling level Never attended school Elementary school Middle school High school University 4 33 7 10 4 6.9 56.9 12.1 17.2 6.9 1 10 3 2 1 5.9 58.8 17.6 11.8 5.9 2 15 3 5 3 7.1 53.6 10.7 17.9 10.7 1 8 1 3 0 7.7 61.5 7.7 23.1 0.0 0.940 Chi-square Live alone Yes No 11 47 19.0 81.0 6 11 35.3 64.7 4 24 14.3 85.7 1 12 7.7 92.3 0.110 Chi-square Smoking habit Yes
No 571 98.31.7 17 0 1000 271 96.4 3.6 130 1000
0.580 Chi-square
Alcohol drinking Never
Once/month or less 2–4 times/month 2–3 times/week 40 14 3 1 69.0 24.1 5.2 1.7 10 5 1 1 58.8 29.4 5.9 5.9 20 7 1 0 71.4 25.0 3.6 0 10 2 1 0 76.9 15.4 7.7 0.0 0.712 Chi-square
Table 2
Association tests and P values for the variables of subjective health assessment according to the classifi cation of frailty
Variable NF PF F P Test
n % n % n %
Health self-assessment Excellent Good Fair Poor Very poor 0 9 6 2 0 0.0 52.9 35.3 11.8 0.0 4 10 13 0 1 14.3 35.7 46.4 0.0 3.6 0 4 8 1 0 0.0 30.8 61.5 7.7 0.0 0.200 Chi-square
Comparison of health with others of the same age Equal Better Worse 3 13 1 17.6 76.5 5.9 9 15 4 32.1 53.6 14.3 1 9 3 7.7 69.2 23.1
0.301 Fisher exact
Current health x previous year Equal Better Worse 9 2 6 52.9 11.8 35.3 6 4 18 21.4 14.3 64.3 1 6 6 7.7 46.2 46.2
0.016* Fisher exact
Health care Excellent Good Fair Poor 1 11 5 0 5.9 64.7 29.4 0.0 5 17 5 1 17.9 60.7 17.9 3.6 5 5 3 0 38.5 38.5 23.1 0.0
0.301 Fisher exact
Activity level as compared with that of the previous year Equal Better Worse 12 0 5 70.6 0.0 29.4 9 5 14 32.1 17.9 50.0 2 1 10 15.4 7.7 76.9
0.010* Fisher exact
NF: non-frail; PF: pre-frail; F: frail. *Statistically signifi cant (95% confi dence).
The subjective assessment of health (Table 2) showed an association of frailty with the following: the comparison of current health with that of the previous year; and the current activity level as compared with that of the previous year. The other items showed no significant differences between the groups.
The elderly had, on average, 3 ± 1 distinct comorbidities, and no signifi cant difference was found between the frailty classes (P = 0.326). In isolation, only depression showed a signifi cant association with frailty. Only three (17.6%) NF elderly reported depression as compared with 15 (53.6%) PF elderly and seven (61.5%) F elderly (P = 0.041).
Using the GDS, nine (52.9%) NF elderly and 20 (71.4%) PF elderly showed no symptoms of depression. Regarding the F elderly, eight (61.5%) had symptoms. However, Fisher exact test showed no signifi cant association between frailty and the presence of depression according to the GDS (P = 0.118).
Regarding the number of medications used (Table 3), a signifi cant difference between the frailty classes was observed (P = 0.001). The NF elderly differed from the PF and F elderly (P = 0.038 and P = 0.001, respectively). No difference was observed between the PF and F elderly (P = 0.102).
Regarding the BMI (Table 3), the mean for the 58 el-derly was 30.00 ± 6.00 kg/m2. When assessed in each group, the mean BMI differed significantly between the frailty classes (P = 0.018). The mean BMI of the NF elderly was 27.00 ± 4.5 kg/m2, and that of the F elderly was 34.00 ± 8 kg/ m2. The multiple comparisons evidenced that PF and F elderly were similar regarding the BMI (P = 0.138). On the other hand, the NF elderly differed from both the PF (P = 0.041) and F (P = 0.013) elderly.
Table 3
Comparison of medication use, BMI and FES–I score between frail, pre-frail and non-frail elderly
NF PF F Statistics P
Currently used medications Mean SD Median
4 2 3
5 2 5
7 2 8
F = 8.155** 0.001*
BMI Mean SD Median
27.45 4.53 25.42
29.94 4.05 29.55
34.03 8.08 34.17
χ² = 8.021*** 0.018*
FES–I Mean SD Median
29 9 28
31 11 30
41 12 44
χ² = 8.125*** 0.047*
NF: non-frail; PF: pre-frail; F: frail; BMI: body mass index (kg/m2); FES–I (Brasil): Falls Effi cacy Scale – International. *Statistically signifi cant (95% confi dence); **ANOVA: Analysis of variance; ***Kruskal-Wallis test.
On the contrary, when assessing the FES-I scores (Table 3), the multiple comparisons indicate that the PF and NF elderly were similar (P = 0.851), while the F elderly differed from both the PF (P = 0.014) and NF (P = 0.005) elderly.
In addition, the WOMAC index was assessed in its three domains (Table 4). A signifi cant difference was evidenced in the physical function domain (P = 0.023). The multiple comparisons indicated a similarity between the NF and PF elderly (P = 0.159), as well as between the PF and F elderly (P = 0.365). A signifi cant difference was observed between the two extremes: the F and NF elderly (P = 0.019).
Of all the elderly studied, 54 (93%) had knee OA. The median duration of symptoms was 54 months (P25 = 36; P75 = 165) for the NF elderly, 60 months (P25 = 48; P75 = 150) for the PF elderly, and 120 months (P25 = 60; P75 = 210) for
the F elderly. Despite the highest median for the F elderly, no signifi cant difference was observed between the frailty levels (P = 0.37).
The distribution of the NF elderly with knee OA accor-ding to the Kellgren-Lawrence graaccor-ding scale was as follows: grade I, six (37.5%); grade II, four (25%); and grade III, six (37.5%). That distribution of the PF elderly was as follows: grade I, fi ve (20%); grade II, seven (28%); and grade III, 13 (52%). Regarding the F elderly, that distribution was as follows: grade I, two (15.4%); grade II, six (46.2%); grade III, three (23.1%); and grade IV, two (15.4%). The Fisher exact test showed no signifi cant association between frailty and the Kellgren-Lawrence grading scale.
Only seven elderly in the sample (12%) were diagnosed with hip OA, with a median duration of symptoms of 90 months (P25 = 12; P75 = 60) for the NF, of 96 months (P25 = 24) for the PF, and of 96 months for the F elderly. No signifi cant difference was observed between that variable and the frailty levels (P = 0.775). In addition, the Kellgren-Lawrence grad-ing scale showed no signifi cant differences between the frailty levels (P = 1.00).
DISCUSSION
This study aimed at assessing the characteristics of the elderly with knee and/or hip OA, focusing on the frailty syndrome.
A signifi cantly higher number of women comprised our sample, and the fi rst explanation for that might be the source of the sample data, in which women were the majority (404 women and 203 men). In addition, it has been reported that knee OA,3,18 which also comprised most of the study sample, is more prevalent in women. Another aspect relates to the question that led us to those elderly, regarding their diagnosis with arthritis or rheumatism by a physician. Such question may represent a bias, because studies have shown that women seek medical care more often than men do,19,20 and, thus, it is believed that women are more likely to have diseases diagnosed by a physi-cian as compared with men.
The percentage of the F elderly found (22.41%) differs from those in the literature. Fried et al.6 have reported 6.9% of F elderly. Cesari et al.10 have reported 8.8%, and Santos21 has found 13.2% of those individuals. Even when compared with the fi ndings by Santos-Eggimann et al.,22 who have assessed frailty in 10 European countries and have found a mean of 17% of F elderly, the prevalence found in the pres-ent study remains greater. It is believed that the fact that this study’s sample comprised only elderly with OA might
Table 4
Descriptive statistics, Kruskal-Wallis test, ANOVA, and P values according to the pain, stiffness, and function WOMAC domains
WOMAC NF PF F Statistics P
Pain Mean SD Median
34.41 20.30 35.00
35.71 21.89 35.00
43.85 28.81 45.00
F = 0.716 0.493
Stiffness Mean SD Median
38.24 24.40 37.50
47.77 35.85 50.00
39.42 32.21 50.00
χ² = 1.096 0.578
Function Mean SD Median
30.10 17.80 35.29
42.66 23.55 43.38
52.71 23.03 50.00
F = 4.037 0.023*
have infl uenced the results, since a signifi cant association between OA and frailty has already been reported.10,11 The higher number of women in the present study might also be an explanation, since there is evidence that they tend to be more frail then men.6,23 Nevertheless, the prevalence of frail female elderly in the Cardiovascular Health Study
(CHS) was 7.3%6 and in The Women’s Health and Aging
Studies (WHAS), 11.3%.23 Another explanation would be Brazilian's ethnic mixture since its origin. In the study by Cesari et al.,10 while Switzerland and Sweden had 5.8% and 8.6% of F elderly, respectively, Italy and Spain had 23% and 27.3%, respectively.22 In an attempt to explain those differences, a study with Afro-Americans (AAM) and European-Americans (EA) has assessed the percentage of elderly in each frailty group using two different cut-off points: one unadjusted for ethnicity and the other adjusted for ethnicity.24 When the unadjusted cut-off point was used, a greater percentage of frail individuals was found in the AAM group. That difference disappeared when the cut-off point adjusted for each ethnicity was used. At least part of that difference is believed to occur due to differences in the BMI and height among ethnicities, variables used to establish cut-off points for grip strength and walking speed, respectively.24 Along that same line, Santos,21 assessing Brazilian older adults, has also reported a difference among the frailty groups after adjusting the Fried’s cut-off points for the population studied. While for the original cut-off points the prevalences of frailty and PF were 13.27% and 49.29%, respectively, after adjusting, both groups showed a reduction, passing to 10.6% and 43.36% for F and PF groups, respectively.21 However, even if the difference in the cut-off point explains part of the present study’s fi ndings, the frailty prevalence, as compared with the unadjusted data of Santos,21 remains higher.
Regarding the subjective health assessment, the items analyzing the current health status and activity level as compared with those of the previous year showed an asso-ciation with frailty. The number of the F elderly reporting worsening of their health status as compared with that of the previous year was the same of those reporting an im-provement. On the contrary, in the PF group, most elderly reported worsening of their health status as compared with that of the previous year. Regarding the current physical activity level as compared with that of the previous year, both the F and PF elderly reported worsening. The cross-sectional characteristic of this study does not allow stating the causes of those changes, but, based on the literature, one can speculate about some of them.
Health self-assessment is known to predict, in a robust and consistent way, mortality and functional decline,25 and frailty has already been observed to relate to those aspects. Thus, the first justification could be the dynamic charac-teristic of frailty,26 as follows: the elderly who currently report worsening could be, in the previous year, in an-other frailty category, considering the frailty phenotype.6 That, however, does not explain the percentage of the F elderly reporting an improvement in their health status. The functional capacity has a floating characteristic,27,28 which might explain the reported improvement by part of the F elderly, who, despite remaining in the same frailty category, might have moved to a better level of functional capacity, and, thus, acquired a better perception of health. It might still explain the worsening previously described, since the transition can occur in both directions. In ad-dition to the questions related to frailty, pain in OA has also floating characteristics,29 which can justify part of the changes in self-perception.
Contrary to that reported in the literature,6,11,30 this study showed no signifi cant difference in the number of comorbidities among the frailty groups (the mean number was the same in all three groups). Although this does not corroborate the fi ndings of other studies,6,11,30 the lack of association between comorbidity and frailty emphasizes the concept that frailty is a distinct clinical syndrome.6,7 On the other hand, the fact that OA is a disease with a high comorbidity rate31,32 might have hindered the identifi cation of differences among the groups.
the present study made the criterion “depression diagnosed by a physician” more sensitive to demonstrate the association between depression and frailty as compared with the GDS.
Another important aspect well-described in the literature is that OA, depression and frailty, in isolation, are risk factors for incapacity.4,6,7,33,34 In addition, depression has been related to worse functioning in the elderly with OA.35,36 The present study, in which all the elderly have OA, showed that the F elderly are even more depressed than the NF elderly. Thus, the elderly diagnosed with simultaneous OA, depression and frailty should be carefully considered, because they are at higher risk of developing future incapacity.
Although this study found no association between co-morbidity and frailty, it showed that the F elderly use a signifi cantly greater number of medications as compared with the NF elderly. One explanation for that fi nding could be that the severity rather than the number of comorbidities might be more associated with frailty. The higher number of medications might be one way of refl ecting the severity of comorbidities. Another aspect reported in the literature is that some adverse effects of the medications can contribute to frailty.37 However, the present study does not allow
con-fi rming those hypotheses, and further studies are required to better clarify that question.
The elderly of the present study tended towards obesity, which is a known risk factor for the development and pro-gression of OA38,39 and has effects on the progression of the functional limitation and incapacity of the elderly with that condition.4,40 Some studies have evidenced an association between obesity and frailty,41,42 as well as a greater risk of incapacity in the elderly with sarcopenic obesity.41,43 When assessed according to frailty group, the BMI proved to be signifi cantly greater in the PF and F groups than in the NF group. Those fi ndings suggest that the elderly with OA and frailty have a greater tendency towards obesity, and, in the presence of the three conditions, a higher risk for functional limitation.
The assessment of the number of falls in the last 12 months showed no signifi cant difference among the groups. However, although non-signifi cant, the F group showed a tendency to-wards a greater percentage of elderly with at least two falls, and recurring falls are the ones that most predict negative outcomes.44 The results of the present study differ from those of other studies,6,30 which show an association between fall and frailty. Because knee and/or hip OA is a predisposing factor to falls, that may have been one of the reasons for not fi nding an association with frailty in this study, which strengthens the multifactorial character of the etiology of falls.45 Another
question is that the elderly can both forget their falls and ne-glect their occurrence,44 which infl uences the results obtained in the investigation.
The outcome “fall” was also assessed by use of the FES-I-Brasil.15 When classi
fi ed as non-fallers, fallers and recurring fallers, no signifi cant difference was observed among the groups, although recurrent falls were more com-mon in the F and PF groups. When the total scores were used, an association was found between the F group and higher scores, evidencing that the elderly with OA and frailty are more concerned about falling, indicating a lower fall-related self-effi cacy. An explanation for those apparently discordant results would be that the original cut-off points for the classifi cation of non-fallers, fallers and recurring fallers in the sample of the adaptation study of FES-I to Brazil do not have the same sensitivity in a sample in which all the elderly have knee and/or hip OA – thus, the total score might be more appropriate for the present study. A tendency towards a greater percentage of elderly classifi ed as recurring fallers in the F and PF groups is observed, as is an association between F elderly and worse fall-related self-effi cacy when using the total score of the FES-I. Thus, it is worth noting that both worse fall-related self-effi cacy and recurring falls might lead to physical activity restriction and worse quality of life.15,46
Pain, stiffness and physical function were assessed by use of the WOMAC questionnaire,14 and only physical function showed an association with frailty, having the F group the greatest, and thus worse, mean. This shows that the F elderly with OA of this sample have worse function and might be at a higher risk for progressing with incapacities and dependence than the NF elderly with OA.
Although no signifi cant difference was observed for the “pain” domain, the F elderly had a worse mean than the other groups. It has been reported that pain in OA has a fl oating characteristic.29 The WOMAC sensitive to show any associa-tion between pain and frailty might have been low, because it refers to pain only in the last 72 hours. Because the OA pain is related to functional changes, fatigue, mood swings, worse quality of life, reduced independence, and worse perception of health,47–49 it is believed that studies assessing OA pain and frailty in a more detailed way might bring more relevant information for the clinical practice.
present study assessed whether the radiographic changes were associated with frailty, but that association could not be evidenced. However, the duration of symptoms, although not yet well-defi ned in the literature, seems to be signifi cant for the functional changes.50 In addition, it is believed that the duration of symptoms to be also signifi cant for frailty, and, although this study shows the opposite, another study with similar numbers of elderly with initial and older OA symptoms can better clarify that aspect.
CONCLUSION
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